Dyspepsia differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ajay Gade MD[2]]

Overview

Dyspepsia must be differentiated from other diseases that presents with epigastric pain such as gastritis, gastroesophageal reflux disease, acute pancreatitis, primary biliary cirrhosis, cholelithiasis, gastric outlet syndrome, myocardial infarction, pleural empyemae appendicitis

Differentiating Dyspepsia from other Diseases

Dyspepsia must be differentiated from other diseases that presents with epigastric pain such as gastritis, gastroesophageal reflux disease,acute pancreatitis,prmary biliary cirrhosis,cholelithiasis,gastric outlet syndrome,myocardial infaraction ,pleural empyema,acute appendicitis [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]
































































Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Fever Rigors and chills Abdominal Pain Jaundice GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders
Acute pancreatitis + − Epigastric ± − ± − − N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Primary biliary cirrhosis − − RUQ/Epigastric + − − − − N Increased AMA level, abnormal LFTs
Cholelithiasis ± − RUQ/Epigastric ± − − + + N to hyperactive for dislodged stone Leukocytosis Ultrasound shows gallstone Murphy’s sign
Gastric causes Peptic ulcer disease ± − EpisodicEpigastric − + in perforated + + N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
 Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Gastritis ± − Epigastric + in chronic gastritis −
Gastroesophageal reflux disease − − Epigastric − − − − −
Gastric outlet obstruction − − Epigastric − − ± Hyperactive
Intestinal causes Acute appendicitis + +in pyogenic appendicitis Starts in epigastrium, migrates to RLQ − − + in perforated appendicitis + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Extra-abdominal causes Pulmonary disorders Pleural empyema + ± RUQ/Epigastric − − − − − N
Cardiovascular disorders Myocardial Infarction − − Epigastric − − + in cardiogenic shock − − N
Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM=Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein 



Disease Cause Symptoms Diagnosis Other findings
Pain Nausea

&

Vomiting

Heartburn Belching or

Bloating

Weight loss Loss of

Appetite

Stools Endoscopy findings
Location Aggravating Factors Alleviating Factors
Acute gastritis Food Antacids ✔ ✔ ✔ - ✔ Black stools -
Chronic gastritis Food Antacids ✔ ✔ ✔ ✔ ✔ - H. pylori gastritis

Lymphocytic gastritis

  • Enlarged folds
  • Aphthoid erosions
 -
Atrophic gastritis Epigastric pain - - ✔ - ✔ ✔ - H. pylori

Autoimmune

Autoimmune gastritis diagnosis include:

Crohn's disease - - - - - ✔ ✔
  • Mucosal nodularity with cobblestoning
  • Multiple aphthous ulcers
  • Linier or serpiginous ulcerations
  • Thickened antral folds
  • Antral narrowing
  • Hypoperistalsis
  • Duodenal strictures
GERD
  • Lower esophageal sphincter abnormalities
  • Spicy food
  • Tight fitting clothing
 ✔

(Suspect delayed gastric emptying)

✔ - - - - Other symptoms:

Complications

Peptic ulcer disease

Duodenal ulcer

  • Pain aggravates with empty stomach

Gastric ulcer

  • Pain aggravates with food
  • Pain alleviates with food
 ✔ ✔ - - - Gastric ulcers
  • Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base
  • Most ulcers are at the junction of fundus and antrum
  • 0.5-2.5cm

Duodenal ulcers

Other diagnostic tests
Gastrinoma - - ✔

(suspect gastric outlet obstruction)

✔ - - - Useful in collecting the tissue for biopsy

Diagnostic tests

Gastric Adenocarcinoma - - ✔ ✔ ✔ ✔ ✔ Esophagogastroduodenoscopy
  • Multiple biopsies are taken to establish the diagnosis
 Other symptoms
Primary gastric lymphoma - - - - - ✔ - - Useful in collecting the tissue for biopsy Other symptoms

Differentials of funtional dyspepsia

Functional dyspepsia should be differentiated from other diseases that cause chronic nausea and vomiting. The differentials include the following:[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50]

Disorder Clinical features Laboratory findings
Chronic nausea Vomiting Diarrhea Retching Lethargy Social withdrawal Photophobia Epigastric pain/burning Lanugo hair Hypogonadism Russel's sign Body mass index (normal range: 18.5 to 24.9) Complete blood count (CBC) Electrolyte imabalance Lipase and amylase levels Gastric scintigraphy Ambulatory esophageal pH and impedance testing
Gastroparesis ✔ ✔ (within 1 hour of eating) - ✔ ✔ - - ✔ - - - ↓ ✔
  • Normal (maybe elevated if chronic renal failure is the cause of gastroparesis- usually less than threefold)
  • Periodic measurement of radiolabeled solid meal:  
    • Grade 1 (mild), 11%-20% retention at 4 h
    • Grade 2 (moderate), 21%-35% retention at 4 h
    • Grade 3 (severe), 36%-50% retention at 4 h
    • Grade 4 (very severe), > 50% retention at 4 h
  • Impedance testing (antroduodenal manometery): Loss of normal fasting migratory motor complexes (MMCs) and reduced postprandial antral contractions and, in some cases pylorospasm
Anorexia nervosa ✔ ✔ ✔ - ✔ ✔ - - ✔ ✔ - ↓ ✔
  • Increased
Bulimia nervosa ✔ ✔ ✔ ✔ ✔ ✔ - - - ✔ ✔ Normal ✔
  • Increased
Rumination syndrome ✔ ✔ (Regurgitation more common- within minutes of meal intake) ✔ - ✔ ✔ ✔ ✔ - - - ↓
  • Normal
 ✔
  • Normal
  • Esophageal pH: Fall in esophageal pH immediately after reguritation (occurs while patient is awake and erect; this is in contrast to GERD, where reflux occurs diurnally and supine position)
Functional dyspepsia ✔ ✔ ✔ ✔ - - - - - - - Normal
  • Normal
 ✔
  • Esophageal pH: May be decreased if patient develops reflux
Cyclic vomiting syndrome ✔ ✔ - ✔ ✔ - - - - - - ↓ ✔
  • Rapid or normal
  • Esophageal pH: Decreased
Pancreatitis ✔ ✔ ✔ ✔ ✔ - - ✔ - - - Normal ✔
  • Increased
  • Not indicated
  • Esophageal pH: Normal
Gastric outlet obstruction ✔ ✔ (within 1 hour of eating) - - - - - ✔ - - - ↓ ✔
  • Esophageal pH: Increased
  • Esophageal manometery:   High manoraetric score

References

  1. ↑ Gralnek IM, Barkun AN, Bardou M (2008). "Management of acute bleeding from a peptic ulcer". N Engl J Med. 359 (9): 928–37. doi:10.1056/NEJMra0706113. PMID 18753649.
  2. ↑ Dallal HJ, Palmer KR (2001). "ABC of the upper gastrointestinal tract: Upper gastrointestinal haemorrhage". BMJ. 323 (7321): 1115–7. PMC 1121602. PMID 11701581.
  3. ↑ Nelson DR, Teckman J, Di Bisceglie AM, Brenner DA (2012). "Diagnosis and management of patients with α1-antitrypsin (A1AT) deficiency". Clin Gastroenterol Hepatol. 10 (6): 575–80. doi:10.1016/j.cgh.2011.12.028. PMC 3360829. PMID 22200689.
  4. ↑ Tsochatzis EA, Bosch J, Burroughs AK (2014). "Liver cirrhosis". Lancet. 383 (9930): 1749–61. doi:10.1016/S0140-6736(14)60121-5. PMID 24480518.
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  22. ↑ Gupta R, Kalla M, Gupta JB (2012). "Adult rumination syndrome: Differentiation from psychogenic intractable vomiting". Indian J Psychiatry. 54 (3): 283–5. doi:10.4103/0019-5545.102434. PMC 3512372. PMID 23226859.
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  27. ↑ Parkman HP (2009). "Assessment of gastric emptying and small-bowel motility: scintigraphy, breath tests, manometry, and SmartPill". Gastrointest. Endosc. Clin. N. Am. 19 (1): 49–55, vi. doi:10.1016/j.giec.2008.12.003. PMID 19232280.
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  31. ↑ Jiang CF, Ng KW, Tan SW, Wu CS, Chen HC, Liang CT, Chen YH (2002). "Serum level of amylase and lipase in various stages of chronic renal insufficiency". Zhonghua Yi Xue Za Zhi (Taipei). 65 (2): 49–54. PMID 12014357.
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  33. ↑ Diamanti A, Bracci F, Gambarara M, Ciofetta GC, Sabbi T, Ponticelli A, Montecchi F, Marinucci S, Bianco G, Castro M (2003). "Gastric electric activity assessed by electrogastrography and gastric emptying scintigraphy in adolescents with eating disorders". J. Pediatr. Gastroenterol. Nutr. 37 (1): 35–41. PMID 12827003.
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  35. ↑ Lee H, Rhee PL, Park EH, Kim JH, Son HJ, Kim JJ, Rhee JC (2007). "Clinical outcome of rumination syndrome in adults without psychiatric illness: a prospective study". J. Gastroenterol. Hepatol. 22 (11): 1741–7. doi:10.1111/j.1440-1746.2006.04617.x. PMID 17914944.
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  38. ↑ Hejazi RA, Lavenbarg TH, McCallum RW (2010). "Spectrum of gastric emptying patterns in adult patients with cyclic vomiting syndrome". Neurogastroenterol. Motil. 22 (12): 1298–302, e338. doi:10.1111/j.1365-2982.2010.01584.x. PMID 20723071.
  39. ↑ "Gastric outlet obstruction - an overview | ScienceDirect Topics".
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  41. ↑ Humphries LL, Adams LJ, Eckfeldt JH, Levitt MD, McClain CJ (1987). "Hyperamylasemia in patients with eating disorders". Ann. Intern. Med. 106 (1): 50–2. PMID 2431640.
  42. ↑ Hempen I, Lehnert P, Fichter M, Teufel J (1989). "[Hyperamylasemia in anorexia nervosa and bulimia nervosa. Indication of a pancreatic disease?]". Dtsch. Med. Wochenschr. (in German). 114 (49): 1913–6. doi:10.1055/s-2008-1066848. PMID 2480214.
  43. ↑ Okada R, Okada A, Okada T, Okada T, Hamajima N (2009). "Elevated serum lipase levels in patients with dyspepsia of unknown cause in general practice". Med Princ Pract. 18 (2): 130–6. doi:10.1159/000189811. PMID 19204432.
  44. ↑ Sansone RA, Sansone LA (2012). "Hoarseness: a sign of self-induced vomiting?". Innov Clin Neurosci. 9 (10): 37–41. PMC 3508961. PMID 23198276.
  45. ↑ Tack J, Caenepeel P, Arts J, Lee KJ, Sifrim D, Janssens J (2005). "Prevalence of acid reflux in functional dyspepsia and its association with symptom profile". Gut. 54 (10): 1370–6. doi:10.1136/gut.2004.053355. PMC 1774686. PMID 15972301.
  46. ↑ "gut.bmj.com" (PDF).
  47. ↑ Boles RG, Williams JC (1999). "Mitochondrial disease and cyclic vomiting syndrome". Dig. Dis. Sci. 44 (8 Suppl): 103S–107S. PMID 10490048.
  48. ↑ Ranasinghe WK, Smith M (2013). "Gastric outlet obstruction with an elevated serum pancreatic lipase secondary to an infraumbilical hernia". Ann R Coll Surg Engl. 95 (7): 122–4. doi:10.1308/003588413X13629960047795. PMID 24112485.
  49. ↑ Ui, Takashi; Shibusawa, Hiroyuki; Tsukui, Hidenori; Sakuma, Kazuya; Takahashi, Shuhei; Lefor, Alan K.; Hosoya, Yoshinori; Sata, Naohiro; Yasuda, Yoshikazu (2015). "Pretreatment of gastric outlet obstruction with pancrelipase: Report of a case". International Journal of Surgery Case Reports. 12: 87–89. doi:10.1016/j.ijscr.2015.05.023. ISSN 2210-2612.

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